Transcript 280211
ICD-10 … The Journey Continues Adelaide M. La Rosa, RN, BSN, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador Director, Clinical Documentation Improvement Program St. Francis Hospital Roslyn, NY Countdown to ICD-10 Oct. 1, 2013? 508 DAYS? May 11, 2012 Flow of Physician’s Documentation Feds Physician’s documentation Converts into codes, ICD-9 now and ICD-10 Oct. 2013? Ranking and reimbursement RAC Oversight and recovery Insurance companies “Tier status” and credentialing HealthGrades LeapFrog Internet Your patient Newsday Diagnosis Codes ICD-9-CM ICD-10-CM 14,025 68,069 Diabetes 5 categories DM due to underlying condition • • • • Drug- or chemical-induced DM • Manifestations • Complication Type 1 DM (Kidney) Type 2 DM (Circulatory) Other specified DM (Retinopathy) (Neurological) Diabetes Mellitus • Type 1 • Type 2 • Secondary DM Diabetes Mellitus • Type 1 diabetes mellitus (E10 – ICD-10-CM category) – Also known as ketosis-prone, juvenile-type, juvenile-onset, or juvenile diabetes – Condition usually develops before reaching puberty – Failure to produce insulin at all or decrease in production – Requires regular insulin injections to sustain life Diabetes Mellitus (cont.) • Type 2 diabetes mellitus (E11 – ICD-10-CM category) – Ketosis-resistant – Insulin produced in insufficient quantity or the body does not use it adequately – Usually does not require insulin – Managed with oral hypoglycemic agents, exercise, and diet – Temporarily may require insulin coverage to control patient’s blood glucose level during hospitalization (Note: Do not use long-term use of insulin if during encounter only) Secondary Diabetes • Caused by: A. Underlying conditions (E08 – ICD-10-CM category) • • • • • • Congenital rubella Cushing’s syndrome Cystic fibrosis Malignant neoplasm Malnutrition Pancreatitis • * Code underlying condition first Secondary Diabetes (cont.) B. Drug induced or chemically induced (E09 – ICD-10-CM category) • * Code responsible drug or chemical first C. Surgical removal of the pancreas D. Infection E. Adverse effect of correctly administered medications, poisoning, or a late effect of using certain medications DM Type 2 With Chronic Complications • Renal • Nervous • Peripheral vascular DM Type 2 With Renal Complications • Nephritis • Nephrosis • Chronic kidney disease DM Type 2 With Renal Complications (cont.) ICD-9-CM ICD-10-CM Diabetes with renal manifestation 250.4X E11.2 Type 2 diabetes mellitus with kidney complications X= 0 Type 2 or unspecified type, not stated as uncontrolled 1 Type 1 [juvenile type], not stated as uncontrolled 2 Type 2 or unspecified type, uncontrolled 3 Type 1 [juvenile type], uncontrolled ICD-9 guideline use additional code to identify manifestations • • CKD Diabetic • Nephropathy • Nephrosis E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complications DM With Ophthalmic Manifestations • Retinopathy – Unspecified – Nonproliferative (with or without macular edema) (mild, moderate, severe) – Proliferative (with or without macular edema) DM With Ophthalmic Manifestations ICD-9-CM 250.5X Diabetes with ophthalmic manifestations ICD-10-CM E11.3XX Type 2 diabetes with ophthalmic complications X= 0 Type 2 or unspecified type, not stated as uncontrolled 1 Type 1 [juvenile type], not stated as uncontrolled 2 Type 2 or unspecified type, uncontrolled 3 Type 1 [juvenile type], uncontrolled E11.31X Type 2 diabetes mellitus unspecified diabetic retinopathy E11.32X Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy E11.33X Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy E11.34X Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy E11.35X Type 2 diabetes mellitus with proliferative diabetic retinopathy E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complications DM With Circulatory Complications (Peripheral Vascular Disease) ICD-9-CM 250.7X Diabetes with peripheral circulatory disease ICD-10-CM E11.5X Type 2 diabetes mellitus with circulatory complications X= 0 Type 2 or unspecified type, not stated as uncontrolled 1 Type 1 [juvenile type], not stated as uncontrolled 2 Type 2 or unspecified type, uncontrolled 3 Type 1 [juvenile type], uncontrolled E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications Dementia • Due to – Direct physiological effects of a general medical condition • For example: – Alzheimer’s disease – Parkinson’s disease • Due to – Senile (with or without acute confusional state) – Alcohol – Vascular (behavior disturbances—with or without) • Documentation of behavioral disturbances, if present, reflect severity of illness of the diagnosis, such as: – Aggressive behavior – Violent behavior – Wandering off – Combative behavior ICD-9-CM Concussion If treatment within 24 to 48 hours of concussion patient is still in acute phase 850.0 Concussion with no loss of consciousness 850.1 Concussion with brief loss of consciousness 850.11 Concussion with loss of consciousness of 30 minutes or less 850.12 Concussion with loss of consciousness from 31 to 59 minutes 850.2 Concussion with moderate loss of consciousness (loss of consciousness for 1–24 hours) 850.3 Concussion with prolonged loss of consciousness and return to pre-existing conscious level (loss of consciousness for more than 24 hours with complete recovery) 850.4 Concussion with prolonged loss of consciousness without return to pre-existing conscious level 850.5 Concussion with loss of consciousness of unspecified duration 850.9 Concussion unspecified ICD-10-CM Concussion If treatment within 24 to 48 hours of concussion patient is still in acute phase SØ6.ØX Concussion √7th SØ6.ØXØ Concussion without loss of consciousness √7th SØ6.ØX1 Concussion with loss of consciousness of 30 minutes or less √7th √7th SØ6.ØX2 Concussion with loss of consciousness of 31 minutes to 59 minutes SØ6.ØX3 Concussion with loss of consciousness of 1 hour to 5 hours 59 minutes SØ6.ØX4 Concussion with loss of consciousness of 6 hours to 24 hours √7th √7th √7th √7th SØ6.ØX5 Concussion with loss of consciousness greater than 24 hours with return to preexisting conscious level SØ6.ØX6 Concussion with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving SØ6.ØX7 Concussion with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness √7th SØ6.ØX8 Concussion with loss of consciousness of any duration with death due to other cause prior to regaining consciousness √7th SØ6.ØX9 Concussion with loss of consciousness of unspecified duration * The appropriate 7th character is to be added to each code from category S Ø 6. A Initial encounter D Subsequent encounter S Sequela Post Concussion Syndrome ICD-9-CM 310.2 Post concussion syndrome ICD-10-CM Fø7.81 Post concussion syndrome * Note: There is no change regarding what needs to be documented Diverticulitis, Diverticulosis, Diverticulum • Specific documentation of progression of disease in order to classify the disease process appropriately Crohn’s Disease • Specify by location – Duodenum – Jejunum – Large bowel – Rectum – Small intestine Crohn’s Disease (cont.) • Specific complication(s) related to Crohn’s disease must be documented to accurately reflect severity of the illness – Abscess – Fistula – Intestinal obstruction – Rectal bleeding Ulcerative Colitis * Noted as with or without complications such as: – Rectal bleed – Fistula – Intestinal obstruction – Abscess Osteomyelitis • Acute • Subacute • Chronic Specific bone Laterality Cellulitis Body part Axilla ICD-9-CM 682.3 ICD-10-CM Laterality needs to be specified LØ3.111 Right LØ3.112 Left Ear 380.1Ø H6Ø.11 Right H6Ø.12 Left H6Ø.13 Bilateral Finger 681.ØØ LØ3.Ø11 Right LØ3.Ø12 Left Orbit 376.Ø1 HØ5.Ø11 Right HØ5.Ø12 Left HØ5.Ø13 Bilateral Toe 681.1Ø LØ3.Ø31 Right LØ3.Ø32 Left Emphysema ICD-9-CM Unilateral pulmonary Centrilobular Panlobular ICD-10-CM J43.Ø 492.8 J43.2 J43.1 Cardiac Arrest Due to • Cardiac condition or specified condition NEC or unspecified If intraoperative, was it during • Cardiac surgery or • Other surgery * Note: Only assigned as secondary diagnosis if cardiac arrest occurs during the hospital episode and patient is resuscitated ASHD Native coronary artery Coronary artery bypass graft • Autologous artery coronary artery bypass graft • Autologous vein coronary artery bypass graft Without angina pectoris With unstable angina pectoris With angina pectoris with documented spasm With other form of angina pectoris With unspecified angina pectoris Cerebral Infarction Diagnoses reflecting severity of illness • Intracerebral hemorrhage • Cerebral thrombosis w/cerebral infarction • Cerebral embolism w/cerebral infarction • Cerebral occlusion/stenosis w/cerebral infarction Documentation requirements include: • Acuity • Location • Laterality • What is the affected side? Dominant or nondominant? • Residual effects Cerebral Infarction (cont.) Document CVA sequela, for example: Alteration of sensations, aphasia, apraxia, ataxia, cognitive deficits, disturbances of vision, dysarthria, dysphagia, dysphasia, facial droop, facial weakness, fluency disorder, hemiplegia/hemiparesis (dominant, nondominant), monoplegia (dominant, nondominant—lower or upper), paralytic syndrome (bilateral, dominant, nondominant), speech and language deficit, stuttering, vertigo Pre-cerebral arteries – Vertebral – Basilar – Carotid The location/origin of the thrombosis, embolism, and occlusion or stenosis of the pre-cerebral artery if the cause of cerebral infarction must be documented Myocardial Infarction • • • • Onset date ST or non-ST elevations Site Coronary artery involved Asthma • • • • Mild intermittent Mild persistent Moderate persistent Severe persistent Fractures • • • • • Type (Gustilo open fracture classification) Specific anatomical site Displaced or not Laterality Type of encounter Bone, Joint, and Muscle • • • • Site Laterality Stages at healing Episode of care Laterality (Right/Left) • • • • • • • • • • • • Cancers Cerebral infarction Pressure ulcers Extremity atherosclerosis Arthritis Fractures Sprains Injury Joint pain Joint effusion Tears, meniscus, cruciate ligament Dislocation Documentation Clarification (Before Physician Query) Admit diagnosis 428.ø CHF, unspecified (I5ø.9) Principal diagnosis 428.ø CHF, unspecified (I5ø.9) Secondary diagnoses 25ø.øø DM without complication, type 2 or unspecified type, not stated as uncontrolled (E11.9) 585.9 CKD, unspecified (N18.9) New York IP APR DRG information 194 Heart failure NY wt ø.61ø5 MDC øø5 ALOS 5 SOI 1 CIRCULATORY SYSTEM Severity of illness 1 Minor severity of illness Risk of mortality 1 Minor risk of mortality * Codes in RED parentheses are ICD-10 codes Query Sample ACDIS Community Hospital Clinical Documentation Improvement Program PT LABEL Inquiry date__________________ Dear Dr. _____________________ If you concur, please clarify in the progress note your diagnosis or etiology of ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Clinical evidence from chart: ______________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _____________Ext: __________________________________Clinical Documentation Specialist Not a part of permanent medical record. Do not photocopy. Documentation Clarification Before After Admit diagnosis Admit diagnosis 428.ø CHF, unspecified (I5ø.9) Principal diagnosis Principal diagnosis 428.ø CHF, unspecified (I5ø.9) Secondary diagnoses New York IP APR DRG information SOI 1 MDC øø5 250.4ø DM with renal manifestations, type 2 or unspecified type, not stated as uncontrolled (E11.22) 585.3 CKD, stage III (moderate) (N18.3) 581.81 Nephrotic syndrome in disease classified elsewhere (manifestation) (Nø8) V58.67 Long-term (current) use of insulin (Z79.4) 194 Heart failure ALOS 5 428.43 Combined systolic and diastolic CHF, acute on chronic (I5ø.43) Secondary diagnoses 25ø.øø DM without complication, type 2 or unspecified type, not stated as uncontrolled (E11.9) 585.9 CKD, unspecified (N18.9) NY wt ø.61ø5 428.ø CHF, unspecified (I5ø.9) 428.ø CHF, unspecified (I5ø.9) New York IP APR DRG information CIRCULATORY SYSTEM Severity of illness 1 Minor severity of illness Risk of mortality 194 Heart failure NY wt ø.8438 MDC: ALOS 5 SOI 1 005 CIRCULATORY SYSTEM Severity of illness: 2 Minor severity of illness 1 Minor risk of mortality Risk of mortality: * Codes in RED parentheses are ICD-10 codes 2 Minor risk of mortality Documentation Clarification (Before Physician Query) Admit diagnosis 486 Pneumonia, organism NOS Principal diagnosis 486 Pneumonia, organism NOS Secondary diagnoses (J18.9) (J18.9) 428.0 CHF NOS (I5ø.9) 401.9 Hypertension NOS (I1ø) New York IP APR DRG information: 139 - OTHER PNEUMONIA MDC: 4 - DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM Severity of illness: 2 Moderate patient severity of illness Risk of mortality: 2 Moderate patient risk of mortality * Codes in RED parentheses are ICD-10 codes Query Sample ACDIS Community Hospital Clinical Documentation Improvement Program PT LABEL Inquiry date ______________ Dear Dr. ____________________________________ If you concur, please clarify in the progress note, your diagnosis or etiology of ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Clinical evidence from chart: ______________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _____________Ext: __________________________________Clinical Documentation Specialist Not a part of permanent medical record. Do not photocopy. Documentation Clarification Before Admit diagnosis 486 Pneumonia, organism unspecified (J18.9) Principal diagnosis 486 Pneumonia, organism unspecified (J18.9) Secondary diagnosis 428.0 Congestive heart failure, unspecified (I5ø.9) 401.9 Essential hypertension, unspecified benign or malignant (I1ø) 585.3 Chronic kidney disease, stage III (moderate) (N18.3) New York IP APR DRG: 139 - OTHER PNEUMONIA MDC: 4 - DISEASES AND DISORDERS OF THE RESPIRATORY SYSTEM After Admit diagnosis ø38.9 Unspecified septicemia (A41.9) Principal diagnosis ø38.9 Unspecified septicemia (A41.9) Secondary diagnosis 5ø7.ø Pneumonitis due to inhalation of food or vomitus (J69.ø) 995.91 Sepsis 428.42 Combined systolic and diastolic heart failure, chronic (I5ø.42) 428.ø Congestive heart failure, unspecified (I5ø.9) 4ø4.11 Benign hypertensive heart and chronic kidney disease stage I through stage IV, or unspecified, with heart failure (I13.ø) 585.3 Chronic kidney disease, stage III (moderate) (N18.3) New York IP APR DRG 72ø SEPTICEMIA & DISSEMINATED INFECTIONS Severity of illness: 2 Moderate patient severity of illness MDC: 18 INFECTIOUS AND PARASITIC DISEASES, SYSTEMIC OR UNSPECIFIED SITES Risk of mortality: 2 Moderate patient risk of mortality Severity of illness: 3 - Major patient severity of illness Risk of mortality: * Codes in RED parenthesis are ICD-10 codes 3 - Major patient risk of mortality Procedure Codes ICD-9-CM ICD-10-PCS 3,824 72,589 Root Operations in the Medical Surgical Section Root operation Definition Example Alteration Modifying the natural anatomic structure of a body part without affecting the function of the body part Face lift, breast augmentation Bypass Altering the route of passage of the contents of a tubular body part Coronary artery bypass (CABG), colonoscopy formation Change Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Urinary catheter change, gastrostomy tube change, drainage tube change Control Stop, or attempting to stop, post-procedural bleeding Control of post-prostatectomy hemorrhage, control of posttonsillectomy hemorrhage Creation Making a new genital structure that does not take over the function of a body part Creation of vagina in a male, creation of penis in a female Destruction Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent Fulguration of rectal polyp, cautery of skin lesion, fulguration of endometrium Detachment Cutting off all or part of the upper or lower extremities Below-knee amputation, disarticulation of shoulder, amputation above elbow Dilation Expanding an orifice or the lumen of a tubular body part Percutaneous transluminal angioplasty, pyloromyotomy, PTCA Root Operations in the Medical Surgical Section (cont.) Root operation Definition Example Division Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part Spinal cordotomy, osteotomy, neurotomy Drainage Taking or letting out fluids and/or gases from a body part Thoracentesis, incision and drainage Excision Cutting out or off, without replacement, a portion of a body part Partial nephrectomy, liver biopsy, breast lumpectomy Extirpation Taking or cutting out solid matter from a body part Thrombectomy, choledocholithotomy, excision foreign body Extraction Pulling or stripping out or off all or a portion of a body part by the use of force Dilation and curettage, vein stripping, suction D&C, D&C7 Fragmentation Breaking solid matter in a body part into pieces Extracorporeal shockwave lithotripsy, transurethral lithotripsy Fusion Joining together portions of an articular body part, rendering the articular body part immobile Spinal fusion, ankle arthrodesis Insertion Putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part Insertion of radioactive implant, insertion of central venous catheter Inspection Visually and/or manually exploring body part Diagnostic arthroscopy, exploratory laparotomy, diagnostic cystoscopy Root Operations in the Medical Surgical Section (cont.) Root Operation Definition Example Map Locating the route of passage of electrical impulses and/or locating functional areas in a body part Cardiac mapping, cortical mapping, cardiac electrophysiological study Occlusion Completely closing an orifice or the lumen of a tubular body part Fallopian tube ligation, ligation of inferior vena cava Reattachment Putting back in or on all or a portion of a separated body part to its normal location or other suitable location Reattachment of hand, reattachment of avulsed kidney, reattachment of finger Release Freeing a body part from an abnormal physical constraint Adhesiolysis, carpal tunnel release Removal Taking out or off a device from a body part Drainage tube removal, cardiac pacemaker removal, central line removal Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function Herniorrhaphy, suture of laceration Replacement Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part Total hip replacement, bone graft, free skin graft Reposition Moving to its normal location or other suitable location all or a portion of a body part Reposition of undescended testicle, fracture reduction Root Operations in the Medical Surgical Section (cont.) Root Operation Definition Example Resection Cutting out or off, without replacement, all of a body part Total nephrectomy, total lobectomy of lung, total mastectomy Restriction Partially closing an orifice or lumen of a tubular body part Esophagogastric fundoplication, cervical cerclage Revision Correcting, to the extent possible, a malfunctioning or displaced device Adjustment of pacemaker lead, adjustment of hip prosthesis, revision of pacemaker insertion Supplement Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part Herniorrhaphy using mesh, free nerve graft, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement, abdominal wall herniorrhaphy using mesh Transfer Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part Tendon transfer, skin pedicle flap transfer, skin transfer flap Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part Kidney transplant, heart transplant Excision vs. Resection OBBKOZZ Excision of right lung, open approach Vs. OBTFOZZ Resection of right lower lung lobe, open approach Note: Review operative report to determine if the intent of the procedure performed is clearly documented Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.